Healthcare Provider Details

I. General information

NPI: 1316041585
Provider Name (Legal Business Name): EDWARD L BARTLETT JR. MD MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 WYMAN PARK DRIVE SUITE 359A
BALTIMORE MD
21211
US

IV. Provider business mailing address

3100 WYMAN PARK DRIVE SUITE 359A
BALTIMORE MD
21211
US

V. Phone/Fax

Practice location:
  • Phone: 410-338-3016
  • Fax: 410-338-3420
Mailing address:
  • Phone: 410-338-3016
  • Fax: 410-338-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD25696
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: